Secondary Logo

Journal Logo

Incorporating Tinnitus Management Services into Your Audiology Practice

Danesh, Ali A. PhD, CCC-A, FAAA

doi: 10.1097/01.HJ.0000612580.66243.2e
Practice Management
Free

Dr. Danesh is a professor in the department of communication sciences and disorders and a professor of clinical biomedical sciences in the Charles E. Schmidt College of Medicine at Florida Atlantic University (FAU). His research focuses on tinnitus, hyperacusis, misophonia, auditory evoked potentials, and vestibular assessment. He is also a consulting clinician at Labyrinth Audiology in Boca Raton, FL, where he treats patients with tinnitus and decreased sound tolerance disorders.

For many individuals, tinnitus is a very disturbing condition that can influence one's daily activities, relationships, and well-being. As audiologists, we encounter these patients on a regular basis; however, many of us miss the opportunity to help them and grow our practice at the same time. The audiological tinnitus evaluation test battery, the application of appropriate tinnitus assessment tools, as well as a variety of scientifically supported and evidence-based tinnitus management strategies, such as counseling, sound therapy, cognitive behavioral therapy, and alternative treatments are discussed in this article.

Back to Top | Article Outline

HISTORY AND PATHOLOGY

For thousands of years, humans have been struggling to cure tinnitus—and this battle may continue for many decades to come. Records in old medical texts cite tinnitus pathology and management, such as Ebers Papyrus from ancient Egypt, Pliny the Elder (23-79 AD), and the work of the Persian physician Avicenna (980-1036) in his book Canon.1 Explaining the history of tinnitus and advancements in managing this condition is always a good strategy for counseling patients with tinnitus.

Tinnitus is a brain phenomenon that can be generated by a variety of factors and disorders, which most audiologists are completely familiar with. However, its origination is still under debate. From a neuroscience point of view, it seems that factors such as central gain and cross-modal compensations in subcortical structures may contribute to tinnitus and its generation.2,3 Furthermore, research literature indicates some electrophysiological findings that confirm the notion that pre-attentive and automatic central auditory processing are compromised in those with chronic tinnitus.4

Back to Top | Article Outline

EVALUATION AND ASSESSMENT

Tinnitus History and Questionnaires. Tinnitus evaluation usually starts with a comprehensive case history interview. The patient is then given a set of questionnaires for the clinician to get a better understanding of the extent of the patient's tinnitus disturbance and the role of hearing loss. These questionnaires include the Tinnitus Handicap Inventory (THI),5 Tinnitus Reaction Questionnaire (TRQ),6 Tinnitus Functional Index (TFI),7 and Tinnitus and Hearing Survey (THS).8 I routinely use TRQ because it includes a question on suicidal thoughts—an important aspect that audiologists need to be aware of. The THS is also important due to its recognition of hearing difficulties as a major contributor to tinnitus annoyance.

Other factors, such as anxiety, depression, and stress, should also be checked. The mental health of tinnitus patients as well as the mental health of their parents have been shown to be important factors when evaluating patients with tinnitus. One of my research collaborators, Hashir Aazh, PhD, and his colleagues have found significant interactions between parental mental health and the level of tinnitus handicap in adults.9-11

Psychoacoustical Tinnitus Assessment. Tinnitus assessment is a recognized CPT procedure under the code 92625. It comprises assessment of tinnitus pitch and loudness, minimal masking level, and residual inhibition (optional). Many clinical guidelines are available for tinnitus assessment; consider the work of Henry, et al.12

Many clinicians may not know the purpose and benefits of performing a tinnitus assessment. I believe it is an important part of a tinnitus visit, and I use the assessment data in my counseling sessions. For example, knowing the tinnitus pitch is important because if the tinnitus is associated with hearing loss, adjusting the hearing aids around the tinnitus pitch or providing a band of sound around that frequency is usually helpful in tinnitus sound therapy. It is also helpful in generating appropriate signals using digital and wearable sound generators. Data on tinnitus loudness can be a useful counseling tool. I usually share the following with a patient at the start of a counseling session: Tinnitus patients can be divided into three groups. Out of the 50 million people who have reported tinnitus in the United States, 35 million of them do not really care about the sound, and, if you measure their tinnitus loudness, it is less than 10 dB SL. The second group includes about 13 million people who find tinnitus annoying and disturbing, which somewhat influences their life; tinnitus loudness in this group is also below 10 dB SL. The remaining two million tinnitus patients are those who are extremely annoyed by it and usually fear that they will lose their jobs and relationships. Then I would ask the patient, “So what do you think the tinnitus loudness is for the third group?” Many patients would respond, “Is it also 10 dB SL?” Patients are always surprised when I give them their data, which show their tinnitus loudness at around 10 dB SL. In the hundreds of tinnitus patients that I have seen, I rarely encountered one with greater than 10 dB tinnitus loudness percept.

Another piece of useful information from tinnitus assessment is the result of the residual inhibition (RI) test. RI is the suppression of tinnitus for a short (or long in some cases) time (seconds to minutes) following the introduction of a masking sound for one minute. Several physiological studies have provided evidence of neural suppression of spontaneous activities during RI13,14 and its repeatability.15 I prefer to use narrowband noise (NBN) around the center frequency of tonal tinnitus to perform an RI evaluation. For many patients, experiencing this suppression of their tinnitus provides hope since they realize that there are ways to manipulate tinnitus loudness.

Back to Top | Article Outline

MANAGEMENT PROTOCOLS, METHODS

Many options are available for tinnitus management—some are effective, some are not. As clinicians, we are encouraged and somewhat obligated to use methods that are ethically feasible and evidenced-based (i.e., supported by research). Just a few years ago, an outstanding clinical practice guideline (CPG) for tinnitus was published.16 This CPG recommended targeted history and physical examination, comprehensive audiological examination, patient education and counseling, hearing aid evaluation (for those with tinnitus and hearing loss), and cognitive behavioral therapy (CBT). It also recommended sound therapy for those with persistent and bothersome tinnitus. The evidence-based guidelines did not support other types of tinnitus management approaches such as the use of medications, supplements, and transcranial magnetic stimulation.16

Sound Therapy and Counseling. This approach has possibly been practiced for hundreds of years. It has been shown that tinnitus can be drowned by other sounds. Historical evidence shows that patients were told to walk by the sea or listen to the streams and creeks to not hear their tinnitus. In the modern world, sound therapy has been accomplished using hearing aids, sound generators, modified musical tracks, among others.17 Interestingly, research literature shows that when patients listen to a prolonged low-level noise, neuroplastic changes occur in the brain, which helps reduce tinnitus percept.18,19

Martin Pinekowski, PhD, introduced a variety of sound therapy stimuli from various scientists and laboratories. These include broadband noise (BBN), filtered BBN combined with music, NBN, music notch-filtered around the tinnitus pitch, and tones combined with electrical stimulations.20

Evidence also shows that the tinnitus experienced by many patients is actually related to their hearing loss. Comprehensive counseling and hearing aid use have been shown to be very effective in managing tinnitus.21

At least three common methods of tinnitus management combine sound therapy and counseling techniques, namely: Tinnitus Activities Treatment (TAT), which involves counseling the whole person;22 Tinnitus Retraining Therapy (TRT), which targets habituation to the reactions evoked by tinnitus;23 and Progressive Tinnitus Management (PTM), which teaches coping skills to reduce functional distress.24

These methods may suggest total or partial masking of tinnitus and mixing point in tinnitus sound therapy. For many clinicians, it can be confusing to determine the most effective method. This dilemma was finally resolved by researchers who found no clinically significant difference between total and partial tinnitus masking.25

Recently, Tyler and colleagues also looked at sound therapy with partial masking alone, in the absence of tinnitus education counseling, to allow for better control. The study was limited, using one patient as its control design and a small sample size of 15 subjects. However, sound therapy proved beneficial to 33 percent of participants, indicating that sound therapy alone can be a useful tool in treating tinnitus.26

Sound therapy-based treatments such as Neuromonics, Desyncra, and the Levo System employ acoustic stimuli to help patients with bothersome tinnitus. Combining these methods with counseling can be beneficial.

Cognitive Behavioral Therapy (CBT). CBT has been shown to be one of the most effective tinnitus management methods. CBT for tinnitus is designed to identify negative automatic thoughts (NATs) and examine the validity and truth behind those negative thoughts. After a few sessions, patients realize that most of these NATs, such as fear, sleep disorders, or poor relationships, are false perceptions. Many European audiology clinics offer CBT to tinnitus patients, and patients have shown positive improvements based on self-report assessments of the handicap caused by tinnitus.27 CBT is the most evidence-based method for tinnitus management.28

Alternative Therapies. Other modes of management and treatment have been examined. One of the most recent methods employs bimodal stimulations. Bimodal auditory-somatosensory stimulation introduces auditory signals while the patient is receiving low-level electrical pulses. This type of therapy for suppressing chronic tinnitus induces long-term depression (LTD) that weakens the connections between neurons.29

The education and knowledge of clinicians, along with their care and empathy for patients, play important roles in tinnitus management. Numerous workshops and continuing education opportunities are available for clinicians to learn more about tinnitus. My hope is that the American Academy of Audiology will offer a specialty in tinnitus like the ones available for pediatric audiology and cochlear implants. Counseling and patient education are extremely important components of tinnitus management in audiology practices. The recommendations of a recent paper by Henry and Manning indicate that an efficient diagnostic/procedural protocol regarding case history, referral, assessment, counseling, treatment, and follow-up services would help promote the standardization of tinnitus therapy approaches and allow for a more effective, evidence-based procedure.30 Finally, I agree with and like the way that Chris Spankovich, AuD, PhD, MPH,31 who described a tinnitus management plan: “It is you as the provider that makes the difference.”

Thoughts on something you read here? Write to us at HJ@wolterskluwer.com

Back to Top | Article Outline

REFERENCES

1. Stephens SDG The treatment of tinnitus—a historical perspective. J Laryngol & Otol. 1984 Vol. 98: 963-972.
2. Auerbach BD, Rodrigues PV, Salvi RJ. Central gain control in tinnitus and hyperacusis. Front Neurol. 2014 Oct 24;5:206.
3. Roberts LE, Eggermont JJ, Caspary DM, Shore SE, Melcher JR, Kaltenbach JA. Ringing ears: the neuroscience of tinnitus. J Neurosci. 2010 Nov 10;30(45):14972-9.
4. Mahmoudian S1, Farhadi M, Najafi-Koopaie M, Darestani-Farahani E, Mohebbi M, Dengler R, Esser KH, Sadjedi H, Salamat B, Danesh AA, Lenarz T. Central auditory processing during chronic tinnitus as indexed by topographical maps of the mismatch negativity obtained with the multi-feature paradigm. Brain Res. 2013 Aug 21;1527:161-73.
5. Newman CW, Jacobson GP, Spitzer JB. Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1996, 122, 143-8.
6. Wilson PH, Henry J, Bowen M, Haralambous G. Tinnitus Reaction Questionnaire: Psychometric properties of a measure of distress associated with tinnitus. J Speech Lang Hear Res. 1991, 34(1), 197-201.
7. Meikle MB, Henry JA, Griest SE, Stewart BJ, Abrams HB, McArdle R, Myers PJ, Newman CW, Sandridge S, Turk DC, Folmer RL, Frederick EJ, House JW, Jacobson GP, Kinney SE, Martin WH, Nagler SM, Reich GE, Searchfield G, Sweetow R, Vernon JA. The tinnitus functional index: development of a new clinical measure for chronic, intrusive tinnitus. Ear Hear. 2012 Mar-Apr;33(2):153-76.
8. Henry JA, Griest S, Zaugg TL, Thielman E, Kaelin C, Galvez G, Carlson KF. Tinnitus and hearing survey: a screening tool to differentiate bothersome tinnitus from hearing difficulties. Am J Audiol. 2015 Mar;24(1):66-77.
9. Aazh H, Landgrebe M, Danesh AA. Parental Mental Illness in Childhood as a Risk Factor for Suicidal and Self-Harm Ideations in Adults Seeking Help for Tinnitus and/or Hyperacusis. Am J Audiol. 2019 Sep 13;28(3):527-533
10. Aazh H, Danesh AA, Moore BCJ Parental Mental Health in Childhood as a Risk Factor for Anxiety and Depression among People Seeking Help for Tinnitus and Hyperacusis. J Am AcadAudiol. 2019 Sep 13;28(3):527-533.
11. Aazh H, Langguth B, Danesh AA. Parental separation and parental mental health in childhood and tinnitus and hyperacusis disability in adulthood: a retrospective exploratory analysis. Int J Audiol. 2018 Dec; 57(12):941-946.
12. Henry JA, Zaugg TL, Schechter MA. Clinical guide for audiologic tinnitus management I: Assessment. Am J Audiol. 2005 Jun;14(1):21-48.
13. Galazyuk AV, Longenecker RJ, Voytenko SV, Kristaponyte I, Nelson GL. Residual inhibition: From the putative mechanisms to potential tinnitus treatment. Hear Res. 2019 Apr;375:1-13.
14. Roberts LE. Residual inhibition. Prog Brain Res. 2007;166:487-95.
15. Deklerck AN, Degeest S, Dhooge IJM, Keppler H. Test-Retest Reproducibility of Response Duration in Tinnitus Patients With Positive Residual Inhibition. J Speech Lang Hear Res. 2019 Aug 21:1-14.
16. Tunkel DE, Bauer CA, Sun GH, Rosenfeld RM, Chandrasekhar SS, Cunningham ER Jr, Archer SM, Blakley BW, Carter JM, Granieri EC, Henry JA, Hollingsworth D, Khan FA, Mitchell S, Monfared A, Newman CW, Omole FS, Phillips CD, Robinson SK, Taw MB, Tyler RS, Waguespack R, Whamond EJ. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014 Oct;151(2 Suppl):S1-S40.
17. Sweetow RW, Sabes JH. Effects of acoustical stimuli delivered through hearing aids on tinnitus. J Am AcadAudiol. 2010 Jul-Aug;21(7):461-73.
18. Sheppard A, Stocking C, Ralli M, Salvi R. A review of auditory gain, low-level noise and sound therapy for tinnitus and hyperacusis. Int J Audiol. 2019 Sep 9:1-11.
19. Sheppard AM, Chen GD, Manohar S, Ding D, Hu BH, Sun W, Zhao J, Salvi R. Prolonged low-level noise-induced plasticity in the peripheral and central auditory system of rats. Neuroscience. 2017 Sep 17;359:159-171.
20. Pienkowski M. Rationale and Efficacy of Sound Therapies for Tinnitus and Hyperacusis. Neuroscience. 2019 May 21;407:120-134.
21. Shekhawat GS1, Searchfield GD, Stinear CM. Role of hearing AIDS in tinnitus intervention: a scoping review. J Am AcadAudiol. 2013 Sep;24(8):747-62.
22. Tyler RS1, Gogel SA, Gehringer AK. Tinnitus activities treatment. Prog Brain Res. 2007;166:425-34.
23. Jastreboff PJ. Tinnitus retraining therapy. Prog Brain Res. 2007;166:415-23.
24. Henry JA, Zaugg TL, Myers PJ, Kendall CJ, Turbin MB. Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise Health. 2009 Jan-Mar;11(42):33-48.
25. Tyler RS, Noble W, Coelho CB, Ji H. Tinnitus retraining therapy: mixing point and total masking are equally effective. Ear Hear. 2012 Sep-Oct;33(5):588-94
26. Tyler, RS, Perreau, A, Powers, T, Watts, A, Owen, R, Ji, H, Mancini, PC. Tinnitus Sound Therapy Trial Shows Effectiveness for Those with Tinnitus. J Am AcadAudiol. 2019 Jun 14. doi:10.3766/jaaa.18027
27. Aazh H & Moore BCJ. Effectiveness of Audiologist-Delivered Cognitive Behavioral Therapy for Tinnitus and Hyperacusis Rehabilitation: Outcomes for Patients Treated in Routine Practice. A J Aud. 2018, 27(4): 547-558.
28. Cima RF, Andersson G, Schmidt CJ, Henry JA. Cognitive-behavioral treatments for tinnitus: a review of the literature. J Am AcadAudiol. 2014 Jan;25(1):29-61.
29. Marks KL, Martel DT, Wu C, Basura GJ, Roberts LE, Schvartz-Leyzac KC, Shore SE. Auditory-somatosensory bimodal stimulation desynchronizes brain circuitry to reduce tinnitus in guinea pigs and humans. SciTransl Med. 2018 Jan 3;10(422).
30. Henry, JA, & Manning, C. Clinical Protocol to Promote Standardization of Basic Tinnitus Services by Audiologists. Am J Audiol. 2019, 28(1s), 152-161.
31. Spankovich, C. (2019). 20Q: Tinnitus-developing a practical management protocol. AudiologyOnline, Article 25780. Retrieved from www.audiologyonline.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.